{"id":3314,"date":"2021-07-06T11:38:24","date_gmt":"2021-07-06T18:38:24","guid":{"rendered":"https:\/\/helloeyelab.com\/?page_id=3314"},"modified":"2021-08-18T19:59:56","modified_gmt":"2021-08-19T02:59:56","slug":"patient-intake-form","status":"publish","type":"page","link":"https:\/\/helloeyelab.com\/cn\/patient-intake-form\/","title":{"rendered":"\u60a3\u8005\u5165\u9662\u8868\u683c"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3314\" class=\"elementor elementor-3314\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4858345 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4858345\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ff5387a\" data-id=\"ff5387a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a012e73 elementor-widget elementor-widget-heading\" data-id=\"a012e73\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Patient Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-677342c elementor-widget elementor-widget-wpforms\" data-id=\"677342c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full eyelab-form phase-2\" id=\"wpforms-3318\"><form id=\"wpforms-form-3318\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"3318\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/cn\/wp-json\/wp\/v2\/pages\/3314\" data-token=\"369b80d9e7d7f806c7bbe07b6e32442d\"><noscript class=\"wpforms-error-noscript\">\u8bf7\u5728\u6d4f\u89c8\u5668\u4e2d\u542f\u7528JavaScript\u6765\u5b8c\u6210\u6b64\u8868\u5355\u3002<\/noscript><div class=\"wpforms-page-indicator circles\" data-indicator=\"circles\" data-indicator-color=\"#6aaae4\" data-scroll=\"1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#6aaae4\">1<\/span><span class=\"wpforms-page-indicator-page-title\">Information<span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-2\"><span class=\"wpforms-page-indicator-page-number\">2<\/span><span class=\"wpforms-page-indicator-page-title\">Extended Health<span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-3\"><span class=\"wpforms-page-indicator-page-number\">3<\/span><span class=\"wpforms-page-indicator-page-title\">Health Concerns<span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-4\"><span class=\"wpforms-page-indicator-page-number\">4<\/span><span class=\"wpforms-page-indicator-page-title\">Contact<span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-3318-field_14-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"14\"><\/div><div id=\"wpforms-3318-field_65-container\" class=\"wpforms-field wpforms-field-html pulled-heading\" data-field-id=\"65\"><div id=\"wpforms-3318-field_65\"><h4>Patient Information<\/h4><\/div><\/div><div id=\"wpforms-3318-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_3\">Name on care card (Last, First) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-3318-field_16-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_16\">Date of Birth (MM\/DD\/YY) <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-3318-field_16\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][16][date]\" placeholder=\"MM \/ DD \/ YYYY\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-3318-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_52\">PHN (Care Card Number) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_52\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][52]\" required><\/div><div id=\"wpforms-3318-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_53\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" required><\/div><div id=\"wpforms-3318-field_54-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_54\">City <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_54\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][54]\" required><\/div><div id=\"wpforms-3318-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_55\">Postal Code <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_55\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][55]\" required><\/div><div id=\"wpforms-3318-field_56-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_56\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_56\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][56]\" required><\/div><div id=\"wpforms-3318-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_57\">Occupation <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_57\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][57]\" required><\/div><div id=\"wpforms-3318-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_58\">Last Eye Exam <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_58\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58]\" required><\/div><div id=\"wpforms-3318-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_50\">Family Doctor <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_50\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][50]\" required><\/div><div id=\"wpforms-3318-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_51\">Referred From <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_51\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][51]\" required><\/div><div id=\"wpforms-3318-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_26\">Reason For Visit <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3318-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" required><\/textarea><\/div><div id=\"wpforms-3318-field_13-container\" class=\"wpforms-field wpforms-field-pagebreak eyelab-form-next\" data-field-id=\"13\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"3318\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  eyelab-form-next\" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-3318-field_66-container\" class=\"wpforms-field wpforms-field-html pulled-heading\" data-field-id=\"66\"><div id=\"wpforms-3318-field_66\"><h4>Extended Health<\/h4><\/div><\/div><div id=\"wpforms-3318-field_40-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"40\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"2\" data-formid=\"3318\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"3318\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-3318-field_67-container\" class=\"wpforms-field wpforms-field-html pulled-heading\" data-field-id=\"67\"><div id=\"wpforms-3318-field_67\"><h4>Health Concerns<\/h4><\/div><\/div><div id=\"wpforms-3318-field_41-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_41\">Computer Usage (hrs\/day) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_41\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][41]\" required><\/div><div id=\"wpforms-3318-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_42\">Contact Lens Wear (hrs\/day) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_42\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][42]\" required><\/div><div id=\"wpforms-3318-field_43-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_43\">Medical History <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3318-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_43_1\" name=\"wpforms[fields][43]\" value=\"Hypertension\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_43_1\">Hypertension<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_43_2\" name=\"wpforms[fields][43]\" value=\"Diabetes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_43_2\">Diabetes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_43_3\" name=\"wpforms[fields][43]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_43_3\">None<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_43_4\" name=\"wpforms[fields][43]\" value=\"Others:\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_43_4\">Others:<\/label><\/li><\/ul><\/div><div id=\"wpforms-3318-field_44-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-3318-field_44\">Medical History (Others) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" required><\/div><div id=\"wpforms-3318-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_45\">Allergies <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_45\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][45]\" required><\/div><div id=\"wpforms-3318-field_46-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_46\">Medications <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_46\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][46]\" required><\/div><div id=\"wpforms-3318-field_47-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_47\">Ocular History <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3318-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_47_1\" name=\"wpforms[fields][47]\" value=\"Glaucoma\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_47_1\">Glaucoma<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_47_2\" name=\"wpforms[fields][47]\" value=\"Macular Degeneration \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_47_2\">Macular Degeneration<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_47_5\" name=\"wpforms[fields][47]\" value=\"Cataracts\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_47_5\">Cataracts<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_47_3\" name=\"wpforms[fields][47]\" value=\"None\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_47_3\">None<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_47_4\" name=\"wpforms[fields][47]\" value=\"Others:\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_47_4\">Others:<\/label><\/li><\/ul><\/div><div id=\"wpforms-3318-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-3318-field_48\">Ocular History (Others) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3318-field_48\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][48]\" required><\/div><div id=\"wpforms-3318-field_49-container\" class=\"wpforms-field wpforms-field-pagebreak flex justify-between\" data-field-id=\"49\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"3\" data-formid=\"3318\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"3318\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4 last flex justify-between\" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-3318-field_68-container\" class=\"wpforms-field wpforms-field-html pulled-heading\" data-field-id=\"68\"><div id=\"wpforms-3318-field_68\"><h4>Contact Information<\/h4><\/div><\/div><div id=\"wpforms-3318-field_60-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_60\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-3318-field_60\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][60]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-3318-field_62-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_62\">Home Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-3318-field_62\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][62]\" required><\/div><div id=\"wpforms-3318-field_63-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_63\">Mobile Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-3318-field_63\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][63]\" required><\/div><div id=\"wpforms-3318-field_64-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-3318-field_64\">Appointment Reminder Preference<\/label><ul id=\"wpforms-3318-field_64\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_64_1\" name=\"wpforms[fields][64]\" value=\"I would like to receive appointment reminders by email\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_64_1\">I would like to receive appointment reminders by email<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3318-field_64_2\" name=\"wpforms[fields][64]\" value=\"I would like to receive appointment reminders by text\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3318-field_64_2\">I would like to receive appointment reminders by text<\/label><\/li><\/ul><\/div><div id=\"wpforms-3318-field_69-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"69\"><div id=\"wpforms-3318-field_69\"><div class=\"boxed-subtle\">\r\n<p style=\"margin-bottom: 32px;\"><strong style=\"text-transform: uppercase;\">Cancellation Policy<\/strong><\/p>\r\n<p>Cancellation of appointment requires a minimum of <strong>24 hour notice<\/strong>.\r\nA $50 cancellation or no-show fee will be required if appointment is cancelled within the 24 hour window.<\/p>\r\n<\/div><\/div><\/div><div id=\"wpforms-3318-field_15-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"15\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"4\" data-formid=\"3318\" disabled>Previous<\/button><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"3318\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"117611781\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-3318\" class=\"wpforms-submit btn btn-primary\" data-alt-text=\"Sending Request...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/helloeyelab.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"\u52a0\u8f7d\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>\u60a3\u8005\u5165\u9662\u8868\u683c<\/p>","protected":false},"author":117611781,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_crdt_document":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-3314","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Patient Intake Form - Eyelab, Doctors of Optometry<\/title>\n<meta name=\"robots\" content=\"index, follow, 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